LAPAROSCOPIC LIVE DONOR NEPHRECTOMY—IS IT SAFE?

Analysis of 80 Consecutive Cases and Comparison with Open Nephrectomy

Abstract

Background. 

Laparoscopic live donor nephrectomy (LDN) is a less invasive alternative to open nephrectomy (ODN) for living kidney donation. Concerns have been raised regarding the safety of LDN, the short and long term function of kidneys removed by LDN, and a potential higher incidence of urologic complications in LDN transplant recipients.

Methods. 

Between October 1997 and May 1999, 80 LDNs were performed at our center. All patients were followed longitudinally with office visits and telephone interviews. These LDNs were compared with 50 ODN performed from January 1996 to October 1997.

Results. 

LDN procedures took significantly longer than ODN (4.6 vs. 3.1 hr). However, LDN was associated with significant reduction in i.v. narcotic use, a rapid return to diet, and shorter hospital stay. Of the 80 LDN procedures, a total of 75 (94%) were completed laparoscopically. Five patients were converted to laparotomy: three for hemorrhage and two for complex vascular anatomy. ODN conversion was associated with large donor body habitus and/or obesity. Seven LDN patients had minor complications and 4 had major complications. All major complications consisted of vascular injuries (2 lumbar vein injuries, 1 renal artery, and 1 aortic injury). All patients made complete recoveries. All LDN kidneys functioned immediately posttransplant. We have observed 100% patient and 97% 1-year actuarial graft survival in LDN transplant recipients. There have been no short-or long-term urologic complications in this series.

Conclusion. 

With increasing experience and standardization of technique, LDN is a safe and effective procedure. Patients undergoing LDN demonstrate clinically significant, more rapid postoperative recoveries and shorter hospital stays than ODN patients. Excellent initial graft function and long-term graft survival have been observed with LDN kidneys. Urologic complications can be avoided. LDN has become the preferred surgical approach for living kidney donation at our center.

There is a steadily increasing disparity between cadaver donor organ supply and demand. United Network of Organ Sharing (UNOS) registry data indicate the number of patients on waiting lists for renal transplants has almost tripled from 13,943 to 38,511 between 1988 and 1997, whereas the number of kidney transplants being performed using cadaver donors increased by only 8%, from 7208 to 7758, during the same period (¹). As one would expect, the waiting time for cadaver organs has also increased; between 1988 and 1996 the mean waiting period for a kidney increased from 400 to 824 days. Consequently, living donors have assumed increasing importance in renal transplantation. Living donors accounted for 3,700 (30%) of the 11,458 kidney alone transplants reported to UNOS in 1997, more than double the 1809 reported in 1988 (¹).

There are several advantages to living donor renal transplantation. The use of living donors is associated with improved patient and graft survival. UNOS registry reports for 1995–1996 live donor 1-year patient and graft survival rates of 97.2% and 91.2% respectively, compared with 1-year cadaveric donor patient and graft survival rates of 93.3% and 80.6%. At 3 years, patient and graft survival rates for living donor transplants are 94.3% and 83.9%, respectively, whereas cadaveric organ survival rates have fallen to 87.4% and 69% (²). Improved graft survival has been observed for recipients of both living-related and living-unrelated allografts. Living donor transplantation helps avoid the prolonged waiting times for a cadaveric organ, and offers the ability to plan such a transplant in advance. Other advantages of live donor renal transplantation include a decreased incidence of delayed graft function and shorter recipient hospitalization. Furthermore, the elective nature of the live donor procedure allows for optimization of the recipient’s medical condition before surgery.

Live renal donation has been performed since the 1950s. Longitudinal studies of patients undergoing unilateral nephrectomy have not shown them to have an increased incidence of renal failure or diseases attributable to having donated a kidney (^3–5). Currently, live renal donation is most commonly performed through a retroperitoneal flank incision. The operation is extremely safe, with reported mortality rates of 0.03–0.06% (^6–8). However, this extraperitoneal flank approach is not without minor morbidity. Wound complications including infection and hernia have been reported in up to 9% of patients (⁹). Pneumothorax requiring pleural space drainage may occur. Chronic incisional pain and so-called wound diastasis has been described (^{10, 11}). Patients undergoing a large flank incision have a duration of hospitalization averaging 4–5 days (^{8, 12}). Adequate pain control often requires the use of epidural analgesics and the prolonged use of parenteral narcotics. Return to normal activities is delayed for as long as 6–8 weeks after surgery. Finally, potential donors are commonly concerned about the appearance of the large flank incision.

Advances in technique and the increasing success of laparoscopic solid organ surgery have provided impetus for development of a minimally invasive approach to live renal donation. Potential benefits of a laparoscopic live donor nephrectomy (LDN) include less postoperative pain, shorter hospitalization, less incisional morbidity, more rapid return to normal activity, and improved cosmesis. Moreover, potential advantages of a minimally invasive operation could lead to increased acceptance of the donor operation and expansion of the pool of potential kidney donors.

Several investigators have reported on the technique of laparoscopic live renal donation (^13–15). These series indicate LDN can be performed safely to provide well-functioning organs; they have also emphasized the technical demands of this procedure. To date, LDN has seen limited application at transplant centers, likely because of continuing concerns regarding safety of the donor, as well as the long term outcome in organs procured laparoscopically.

This article compares our experience with LDN and that of a control cohort of participants undergoing traditional open donor nephrectomy (ODN) with a flank incision to determine whether early graft survival, intraoperative variables, and postoperative recovery are similar between LDN and ODN.

PATIENTS AND METHODS

Patient selection.

LDN was performed in 80 patients from October 1997 through May 1999. These laparoscopic donors were compared to a cohort of 50 patients undergoing ODN at our institution from January 1996 until September 1997. The two groups were matched for age, gender, weight and comorbidity. Patient data were obtained from a combination of medical record review and personal and telephone interviews. Operative and postoperative data collected included blood loss, length of operation, length of postoperative hospital stay, time to tolerance of oral diet, parenteral and enteral analgesic use, and complications. Complications were defined as untoward events within the perioperative period that altered patient recovery, prolonged hospital stay, or represented technical deviations during the surgical procedure. Graft function and survival were also compared. Delayed graft function was defined as the need for dialysis because of poor allograft function in the postoperative period. Mean serum creatinine at 1 week and 1 month after transplantation was determined for recipients of laparoscopically procured kidneys.

Evaluation of the potential living kidney donor evaluation has been extensively reviewed elsewhere (^{16, 17}). Potential donors for ODN or LDN were screened thoroughly by medical history, physical examination, electrocardiogram, hematology, coagulation studies, blood chemistry, urinalysis, chest radiograph, infectious disease workup including viral studies, and immunologic studies to determine suitability of the donor-recipient match. Absolute contraindications to live renal donation included ABO incompatibility, positive cross-match, malignancy, infection, hypertension, diabetes, proteinuria (>150 mg/24 hr), renal disease or reduced renal function (creatinine clearance <80 ml/min), microscopic hematuria, urologic abnormalities in donor kidneys, and nephrolithiasis. The presence of two functional kidneys and an assessment of vascular anatomy were determined by high resolution computed tomographic angiography.

Development of an LDN program.

The LDN program at our center was developed through a partnership of transplant and general surgeons with advanced laparoscopic training. Experience gained from LDN in a preclinical large animal model was extremely useful. The same transplantation surgeon has participated in all LDNs performed at our institution. In the first 30 cases, the transplantation surgeon assisted the general surgeon, whereas in the next 20 their roles were reversed. The transplantation surgeon has functioned independently for the last 30 cases. In our experience, participation of a transplantation surgeon with experience in the principles of ODN helps to ensure the suitability of the kidney for subsequent transplantation. A dedicated operating room team participates in all cases.

Operative technique.

All ODNs were performed through a retroperitoneal flank incision. No partial rib resections were performed. The left kidney was removed preferentially because of the longer renal vein that facilitates the recipient operation.

LDN was performed on the left kidney in all cases to maximize renal vein length and to avoid potential poor graft outcome described in the literature with laparoscopically procured right kidneys (¹⁸). LDN left is performed under general anesthesia with the patient placed in the right decubitus position. The operating table is flexed at a point midway between the patient’s iliac crest and ribcage, and a kidney rest is elevated to maximize exposure during the procedure. Positioning of the patient and draping allows, if necessary, for ODN conversion to an extended subcostal or standard flank approach for completion of the procedure. Orogastric suction, Foley catheter bladder drainage, prophylactic antibiotics, and antithrombotic sequential leg compression devices are routinely used. The patient receives bowel preparation with magnesium citrate the night before surgery to help decompress the colon. The operating surgeon stands on the patient’s right, with the camera operator caudad. An assistant and scrub nurse stand on the patient’s left. Two television monitors are placed at the head of the operating room table. Standard laparoscopic instrumentation, along with a 30° laparoscope and ultrasonic scalpel are used. A pneumoperitoneum of no more than 15 mm Hg is created by Verres needle insertion in the left subcostal location. After creation of the pneumoperitoneum, the laparoscope is introduced into the abdomen using a 10 mm Visiport ^TM. Two additional 12-mm operating ports are placed in the left subcostal location, as well as a 5-mm port in the left posterior axillary line. Port placement will vary slightly from patient to patient depending on patient girth and the length of the torso. In four cases, a pneumatic sleeve (Pneumo-Sleeve, Dexterity Inc.) was used to allow for hand-assisted nephrectomy to be performed; port placement was essentially the same in these cases. The operation is conducted as follows: mobilization of the left colon and spleen, dissection of the renal vein, dissection of the renal artery, dissection of the adrenal gland off the upper pole of the kidney, dissection of the ureter, mobilization of the kidney, creation of an extraction incision, systemic anticoagulation, division of the ureter, renal artery, and renal vein, and renal extraction. During the dissection, adequate urine output is maintained through vigorous i.v. hydration. Osmotic diuresis is instituted after volume loading and at the beginning of the vascular dissection, with 12.5 g of mannitol and 10–20 mg of furosemide. Once the kidney is completely free except for its vascular and ureteral attachments, a 6–7 cm extraction incision located either around the umbilicus or in the left lower quadrant is made without violation of the peritoneum. The patient is then anticoagulated with 5000 U i.v. Heparin sodium. The distal ureter is clipped and divided. Division of the renal artery, followed by the renal vein, is performed with a linear vascular laparoscopic stapler. The peritoneum at the extraction incision is opened, and the kidney is delivered through this wound by the surgeon’s hand into an iced saline solution. The staple lines on the allograft are removed, and the kidney flushed with Collins solution. Heparin is reversed with protamine sulfate while the extraction incision is closed. Pneumoperitoneum is re-established and inspection of the operative field is performed. Once hemostasis has been deemed adequate, ports are removed under direct visualization, the abdomen desufflated, and the incisions closed.

Statistical analyses.

Actuarial patient and graft survival rates were determined for recipients of living donor transplants from the time of transplantation. Kidney graft failure was defined as removal, loss of function requiring return to dialysis, or death with a functioning graft. Actuarial survival estimates were calculated using Kaplan-Meier life-table analysis. Intraoperative and postoperative recovery data were compared between LDN and ODN groups using Fisher’s exact t test.

RESULTS

Patient demographics and operative data are shown in Table 1. LDN was attempted in 80 patients and successfully completed in 75 patients (94%). There were five patients who required conversion to laparotomy. Three conversions occurred after vascular injuries, including two lumbar vein injuries and one renal artery injury. One lumbar vein injury occurred in a patient who also experienced partial occlusion of the abdominal aorta by a linear vascular stapler at the level of the renal arteries. This aortic injury was not appreciated until the 1st postoperative day, and required re-operation and aortic reconstruction several months after recovery from the donor operation for persistent signs and symptoms of vascular insufficiency. The one renal arterial injury in our series was caused by a malfunctioning vascular stapler which cut, but did not staple, the artery. In two patients, a combination of obesity and complicated venous anatomy prompted elective conversion to avoid complications. No patients required re-operation in the immediate postoperative period.

Table 1: Patient demographics and operative data

Intraoperative variables and postoperative recovery data for ODN and LDN are shown in Table 2. Mean intraoperative blood loss was comparable between both groups. Overall, LDN took longer to perform than ODN (4.6 vs. 3.1 hr). However, increased familiarity with the procedure has reduced operating times to a mean of 3.6 hr for the last 30 cases. LDN was associated with significant reduction in use of parenteral narcotics compared with ODN (17.2 vs. 38.3 hr). In addition, resumption of oral intake occurred significantly earlier in the LDN versus the ODN group (8.1 vs. 20.9 hr). Furthermore, patients in the LDN group experienced significantly shorter hospital stays compared with the ODN group (2.1 vs. 3.2 days).

Table 2: Intraoperative data and postoperative recovery^a

Graft function and survival data are provided in Table 3. All kidneys removed laparoscopically functioned immediately; no recipients required posttransplant dialysis. Mean serum creatinine at 1 week (1.46±0.2 mg/dL) and 1 month (1.2±0.1 mg/dL) after transplantation were within normal ranges. Graft function continues in 78 of the 80 laparoscopically harvested kidneys (97%); one kidney was lost because of rejection associated with noncompliance with medications, whereas the other was lost to recurrent disease. One year actuarial patient survival has been 100%. This compares favorably with patient and graft survival for recipients of live donor kidneys procured using ODN.

Table 3: Graft function and survival

Perioperative morbidity occurred in nine patients (11%) in the LDN group (Table 4). All complications occurred within the first 30 LDN cases. Injury to the diaphragm in one patient was easily repaired using intracorporeal suturing but was associated with atelectasis postoperatively in the same donor. A serosal bowel injury occurred in one donor who had adhesions from a rectal pull through procedure performed in infancy; this was repaired by suture without incident. The three vascular injuries encountered did not result in the need for blood transfusions but did initiate conversion to ODN. There was no death in either the LDN or ODN group. No urologic complications of stricture or leak have been observed in the recipients of laparoscopically harvested kidneys.

Table 4: Perioperative morbidity: LDN^a

DISCUSSION

There are several concerns with the application of minimally invasive techniques for live renal donation. Patients undergoing donor nephrectomy are healthy individuals subjected to a major surgical procedure entirely for the benefit of another; therefore the operation must be safe. This is no small consideration in light of the technical expertise required for successful completion of LDN. Kidneys removed laparoscopically should provide excellent short- and long-term renal function in transplant recipients. Furthermore, donor obesity, prior abdominal surgery, and abnormal vascular anatomy may greatly affect the ability to successfully complete LDN without conversion to ODN.

Published reports of LDN indicate it is a safe procedure with excellent outcomes (^{13, 14, 19}). There have been no procedure-related deaths. Perioperative morbidity from this procedure has compared favorably with that seen in ODN. A higher incidence of delayed graft function in LDN compared with ODN has recently been reported (¹⁹). However, patient and graft survival compared favorably, with similar mean serum creatinines in the LDN and ODN groups. ODN conversion does occur and is related to both variations in renal vascular anatomy and donor size/obesity. LDN has been associated with statistically significant reductions in hospital stay, use of i.v. analgesics, time to resumption of diet, and time to return of normal daily activities. In addition, an increase in the rate of LDN has been reported by centers using this approach.

At our center, we have performed 80 LDNs from October 1997 to May 1999, with an ODN conversion rate of 6% (5 of 80). ODN conversion was associated with donor obesity and the presence of abnormal vascular anatomy. All patients made complete recoveries. Patients undergoing LDN experienced less postoperative pain, earlier resumption of diet, and shorter hospital stays compared with our previous 50 ODN patients. All kidneys removed laparoscopically functioned immediately, and we continue to observe excellent patient and graft survival in our transplant recipients.

There is clearly a learning curve with LDN. All of our complications occurred in the first 30 cases. Furthermore, 4 of the 5 ODN conversions occurred in the first 40 cases. Developing a greater facility with the operative procedure has led to a reduction in operating room time; for the last 30 cases, LDN has taken an average of 3.6 hr, which compares favorably with ODN (3.1 hr) (Table 2). With refinement of our technique, we have broadened our use of LDN to include obese donors and those with multiple renal arteries and/or veins. Increased risk of urologic complications in recipients of laparoscopically removed donor kidneys has been reported (¹⁹). There were no urologic complications in our series. We attribute this to our limited use of electrocautery during the ureteral dissection and careful attention to the ureteral blood supply during the operation.

The occurrence of an aortic injury during LDN in our series represents a serious and unusual complication. In this instance, plication of the abdominal aorta may have occurred during application of the linear vascular stapler for division of the renal vasculature. Care must be exercised in seating the vascular stapler properly above the aorta when dividing the renal artery so that the tip of the stapler is clearly seen. Similarly, division of the renal vein should be performed only after visually confirming stapler placement anterior to the aorta.

Several other technical points regarding LDN are worthy of mention. Use of the ultrasonic scalpel for dissection of the kidney, especially the renal vasculature and ureter, greatly decreases the chance of injury to vital structures.

In our experience, the venous dissection, especially in instances in which large lumbar branches are present, represents the most challenging aspect of LDN procedure. Aggressive hydration of the patient with crystalloid solution to overcome the negative hemodynamic effects of the pneumoperitoneum should be used. As reported anecdotally by others, we use topical papaverine and lidocaine in an attempt to minimize vasospasm caused by dissection of the vasculature and hence maximize renal perfusion (^{14, 19}). Some centers have advocated the use of a hand-assisted approach for the operation. “ Handoscopy“ offers the advantage of improved tactile dissection and has the potential to minimize warm ischemic time by simplifying the donor kidney extraction process. In our experience, the presently available devices have limitations related to their size and development of air-leaks that have precluded use in the majority of our patients. The use of stapling devices for division of the artery and vein reduces vascular length compared with ODN. We have therefore chosen to limit LDN to left kidneys to maximize vein length for implantation into the recipient. More than 25% of the kidneys removed laparoscopically had multiple renal arteries. Although most cases resulted from vessels with origins separate from the aorta, the application of the vascular stapler in cases of early bifurcation of a single renal artery often created two separate vessels. Multiple vessels were managed by a double-barrel anastomotic technique, or end-to-side anastomosis of a smaller polar artery into the main renal artery, as described by us previously (²⁰).

LDN is technically demanding but nonetheless feasible and can be performed with morbidity and mortality rates comparable to those of ODN, with marked improvements in patient recovery after the LDN approach. The procedure is best performed only by surgeons with well developed laparoscopic skills. Although initial graft survival and function rates are excellent, long-term follow-up is needed. In our experience, LDN increases willingness to donate and thus may help to expand the potential pool of organ donors.